Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident who was found with multiple bruises in a fingerprint pattern on her inner thighs. The resident, who has diagnoses including psychological disorders, schizophrenia, major depressive disorder, and peripheral vascular disease, was noted to be moderately cognitively intact. The care plan required that any allegations or signs of mistreatment, such as physical marks or injuries, be investigated, including conducting skin checks and interviewing staff assigned to the resident's care. Despite this, the facility's investigation into the bruising did not include interviews with male CNAs who had provided care to the resident in the days prior to the discovery of the bruises, even though the bruises were described as looking like fingerprints and the resident had made a statement to a family member implicating a male individual. Additionally, the facility's incident report incorrectly attributed the bruising to the resident being on an anticoagulant, when a review of the resident's medications showed no such prescription. The administrator acknowledged not realizing that aspirin is not classified as an anticoagulant and stated she did not think there were any male staff on the schedule who could have been involved, despite evidence to the contrary. The investigation did not include interviews with all relevant staff, specifically the male caregivers who were scheduled during the period in question, and failed to fully address the resident's and family member's concerns.